Get California Subscriber Enrollment Change Form 2020-2025

Filling out the California Subscriber Enrollment Change Form online is a straightforward process that allows users to update their subscription details efficiently. This guide provides step-by-step instructions to help you navigate each section of the form with ease.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out section A, which includes company information. Provide the company name, customer ID, enrollment unit ID, and unit name or classification. Make sure to also enter the eligibility contact phone number and select the specific plan you are enrolled in.
3. Next, in section B, indicate what changes you are requesting. You can enroll a subscriber, add or remove dependents, update addresses, or change names. Additionally, specify the effective date of enrollment or change, and if it relates to a special enrollment period.
4. In section C, fill out the subscriber and employee information. Include the subscriber's name, Social Security number, date of birth, and home address. Additionally, provide any mailing address if it differs from the home address.
5. Complete the dependent information in section E by indicating if you want to enroll or remove dependents, and specify their relationship to the subscriber. Fill in their names, dates of birth, and Social Security numbers as required.
6. Sign the form in section D to validate your updates. Ensure you date the form and affix the subscriber's signature in the designated box, as this is a required field for all enrollments and changes.
7. Review the completed form for accuracy and completeness. Once satisfied, you may save any changes, download the form, print it out, or share it as necessary.

Complete your changes by filling out the California Subscriber Enrollment Change Form online today.